INTERSTATE COMPACT

ON PLACEMENT

OF CHILDREN

GUIDEBOOK

Revised: 4/21/04

TABLE OF CONTENTS

SECTION IPURPOSE............................................................................................................. 1

SECTION IIPOLICY ................................................................................................................. 2

SECTION IIISENDING AGENCY'S RESPONSIBILITIES......................................................... 3

SECTION IVREQUEST FOR PLACING A WARD OUT OF NEBRASKA ................................. 4

Processing Request through Compact............................................................ 4Cancellation of Request .................................................................................. 4Denial of Request ........................................................................................... 5

SECTION VPLACEMENT IN ANOTHER STATE..................................................................... 6

Emergency Situations ..................................................................................... 6Problems on Visit to Placement ...................................................................... 6Planned, Approved Placements ..................................................................... 6

SECTION VISERVICES TO WARDS PLACED OUT OF STATE ............................................. 7

Placement Disruptions .................................................................................... 7

SECTION VIITERMINATION OF PLACEMENTS ...................................................................... 9

SECTION VIIIHOME STUDY REQUEST FROM ANOTHER STATE ......................................... 10

Outcomes ........................................................................................................ 10Guidelines for Completion ............................................................................... 10Consultation Points ......................................................................................... 11Time Frame ..................................................................................................... 11

SECTION IXACTION FOLLOWING PLACEMENT OF CHILD INTO NEBRASKA ................... 12

Worker Responsibilities .................................................................................. 12

SECTION XRESPONSES TO DIRECT REQUESTS FROM ANOTHER STATE .................... 13

SECTION XIPLACEMENT OF A CHILD WHO IS NOT A WARD THROUGH ICPC ................ 14

SECTION I

PURPOSE

The Interstate Compact (ICPC) is a law that provides for child placement activities to beuniformly conducted among states and clarifies who is responsible for planning,decision-making and payment. Following the compact law helps assure appropriate services tochildren placed across state lines. The procedures and guidelines which follow describe theactions for compliance with the Interstate Compact and quality services to children and families.

SECTION II

POLICY

Compliance with the Interstate Compact is required when a child is placed into another state toreside in any of the following:

- Adoptive home; - Foster home; - Group home; - Relative home, including the home of a parent, when the child is under the jurisdiction of a

court; or- Child caring agency; or- Residential Treatment Centers.

The Interstate Compact on Placement of Children does not apply to the placement of childreninto another state to reside in the following:

- Inpatient hospitals or other medical facilities; - Boarding schools; or

- Home of a "near relative" when placed by a parent or legal guardian and the child is notunder the jurisdiction of a court; or

- Job Corps placements.

Note: A "near relative" is defined as the parent, step-parent, grandparent, adult brother orsister, adult uncle or aunt or other non-agency guardian of the child.

Note: If a ward is placed in an inpatient psychiatric hospital setting in an out-of-state program,compliance with the ICPC is not required. If the child moves from the inpatient setting to agroup home, even one operated by the same program as the hospital, ICPC compliance andapproval is required.

SECTION III

SENDING AGENCY'S RESPONSIBILITIES

While the child remains in the out-of-state placement, the sending agency retains legal andfinancial responsibility for the child. Sometimes a child is eligible for assistance in the otherstate through programs such as ADC relative payee. The sending agency has both theauthority and the responsibility to determine all matters in relation to the custody, supervision,care, treatment, and disposition of the child, just as the sending agency would have if the childhad remained in the home state.

The sending agency's responsibilities for the child continue until it legally terminates theinterstate placement. It may terminate the placement by returning the child to the home state,or the placement may be terminated with the child left in the receiving state when the child islegally adopted, becomes self-supporting, or reaches majority, or for other reasons with the priorconcurrence of the of the receiving state.

The sending agency must notify the receiving state's Compact Administrator of any change inthe child's status, using Form ICPC 100B. Changes of status may include a termination of theinterstate placement, a new placement of the child in the receiving state or a transfer of legalcustody.

NOTE: FEDERAL STATUTE (ADOPTION AND SAFE FAMILIES ACT) REQUIRES THAT IF ACHILD IS IN PLACEMENT OUTSIDE OF THE STATE IN WHICH THE PARENTS ARELOCATED, A CASEWORKER ON THE STAFF OF THE STATE AGENCY IN WHICH THEHOME OF THE PARENTS IS LOCATED, OR OF THE STATE IN WHICH THE CHILD ISPLACED, VISIT SUCH HOME OR INSTITUTION AND SUBMIT A REPORT ON SUCH VISITTO THE STATE AGENCY OF THE STATE IN WHICH THE HOME OF THE PARENTS ISLOCATED. THIS ACTIVITY MUST OCCUR PERIODICALLY, BUT NO LESS FREQUENTLYTHAN EVERY 12 MONTHS.

SECTION IV

REQUESTS FOR PLACING A WARD OUT OF NEBRASKA

Nebraska remains legally and financially responsible for all wards placed out of state underICPC. The Nebraska court case must remain open until the placement out of state is stablizedand the compact administrator in the receiving state gives Nebraska permission to close thecourt case. There is no process to transfer court cases across state lines.

The Worker Checklist provides a step by step guide to the issues that need to be considered,the forms that need to be completed, and the information about the child that needs to beprovided. Packets that provide the information requested will be processed more quickly andplacements are more likely to be successful.

Processing of Request Through Compact

Upon the receipt of the packet, the ICPC Administrator will either:

- Contact the worker if clarification is needed; or - Make copies as needed and forward two copies of the packet to the receiving state.

Cancellation of Request

If the worker decides not to pursue the Home Study after a request has been made, she/heneeds to let the other state know. The worker will complete Form ICPC 100-B, "InterstateCompact Report on Child's Placement Status" and indicate the date of the cancellation of therequest. The worker will send the form to the Compact Administrator for forwarding to the otherstate.

If the worker decides not to place the child in the other state, once an ICPC approval has beengiven, the worker will let the other state know. The worker will follow the procedure in theparagraph above.

Denial of Request

If the other state denies the request for placement, the worker will complete Form ICPC 100B,"Interstate Compact Report on Child's Placement Status" and indicate the date of withdrawal ofthe request.

SECTION V

PLACEMENT IN ANOTHER STATE

Emergency Situations

Placement of a child into a treatment program in an emergency requires prior approval throughICPC. The worker will contact the Nebraska Compact Administrator after he/she knows theprovider has an opening and will accept the child. The worker will fax or mail to the CompactAdministrator the completed Form ICPC 100A, current court order and a brief letter explainingthe circumstances, child's needs and the plan. Nebraska's Compact Administrator will promptlyadvise the worker of the other state's decision. The worker will send the rest of the packetmaterial to the Compact Administrator as soon as possible if the child's placement is approved.

Visitation

Children may visit a potential placement resource in another state without approval of the otherstate. Visits cannot exceed thirty (30) days, or under some circumstances, summer vacation.Nebraska retains full responsibility for the child’s safety during visits, and no services will beprovided by the receiving state. States will not do home studies for visitation only. Nebraskacan contract privately with agencies in the other state if that service is needed. Do not placechildren in the other state and call it a visit. If the child is there longer than 30 days or isenrolled in school, this is considered an illegal placement. Many states are refusing to do homestudies or provide supervision if the child is placed without approval.

Planned, Approved Placements

Approvals are valid for six (6) months. Upon receipt of the approved Form 100A and the homestudy, the worker will:

- Advise in writing the family, court, parents’ attorney, county attorney, guardian ad litem ofthe placement plan seven (7) days prior to placement.

- Continue the steps in the worker checklist.

Priority Processing of Home Study Requests

In some situations it is possible to request priority processing of home study requests. Aspecific court order is required with a finding that the request qualifies for priority processingbecause the proposed placement is a near relative; the child is under two (2) years of age, is inan emergency shelter, or has spent a substantial amount of time in the home of the proposedplacement. Priority processing can also be ordered if the receiving state administrator has hadthe ICPC packet for more than thirty (30) days without a placement decision about placementmade no later than twenty (20) business days after receipt of the request. Overnight mail is tobe used at every step of the process.

To request a priority home study, complete Form ICPC-101 and sent it to the NebraskaCompact Administrator along with the other packet material. You must include an order fromthe court with a specific finding that the situation qualifies for priority processing

Form ICPC-102, a home study outline, is recommended if Nebraska is requested to do a homestudy that qualifies for priority processing. The is form can be hand written.

To request a priority home study, complete Form ICPC-101 and send it to the NebraskaCompact Administrator along with the other packet material. You must include an order fromthe court with a specific finding that the situation qualifies for priority processing.

Form ICPC-102, a home study outline, is recommended if Nebraska is requested to do a homestudy that qualifies for priority processing. This form can be handwritten.

If you have questions about priority processing, please contact the compact office forassistance.

SECTION VI

SERVICES TO WARDS PLACED OUT OF STATE

The responsibilities of the worker in the state where the child is placed include, but are notlimited to:

- Visit the child and family as needed; - Provide supervision; - Work with the sending worker and family toward the case goal; - Arrange for or coordinate services as identified in case plan; - Problem-solve with or assist the family as needed;

- Document all contacts, reports, progress of child and family and other relevant information;- Provide written reports quarterly to the sending caseworker.

The responsibilities of the worker who has placed a child out of the state is to provide ongoingcase management including:

- Clearly communicate case goals and expectations for the provider and worker supervisingthe case;

- Inform the other worker supervising the case, of relevant information; - Review services being provided to be certain they are appropriate; - Prepare and revise case plan and court reports and share with other worker supervising

the case; - Work with the worker supervising the case toward the case goal; - Cooperate with reviews by Foster Care Review Board; - Attend court hearings; - Document contacts with worker supervising the case, biological family, child, care provider,

court, etc.

The responsibilities of the Compact Administrator include:

- Consultation, support and assistance to staff;- Communication with staff and others to achieve placement outcomes identified by the

worker;- Approve or disapprove placements based on the recommendation of the caseworker;

- Negotiation of reasonable response times to requests; and - Maintenance and processing of necessary documentation on all ICPC cases.

Placement Disruption

If a child's placement in another state disrupts, the Nebraska worker and worker in the otherstate will assess the situation and decide whether:

- Services can be provided to continue the placement; - An alternative placement is needed in the other state; or - The child needs to return to Nebraska.

This decision will be based on the health, safety, and welfare of the child. The case worker mayalso include the biological family, guardian ad litem, service providers or the county attorney inthis decision.

If there are no family members in Nebraska, the best placement for the child may be in the otherstate near the parent, relative or pre-adoptive family with whom the child was placed to worktoward reconciliation. An interim placement may be appropriate while alternative placements orservices are arranged. An interim placement may be appropriate while alternative placementsor services are arranged. If the other state demands the return of the child to Nebraska, andthe caseworker does not agree with this decision, please discuss this with the compactadministrator. Compact law may require the child’s return to Nebraska.

The court and involved attorneys will need to be advised in writing of any changes in the child'splacement seven days prior to the placement change except in emergency situations. In anemergency, the court will be advised the next working day.

The ICPC Form 100B will need to be completed to reflect a change in the child's placement.

SECTION VII

TERMINATION OF PLACEMENTS

When the worker determines that a placement into another state will be terminated, the workerwill complete Form ICPC 100B, "Interstate Compact Report on Child's Placement Status" toshow:

- The date; and - Reason for termination: - Adoption finalized, - Child reached age of majority, - Legal custody awarded to parent, - Treatment is completed, - Sending states jurisdiction is terminated, - Child returned to sending state, or - Other reason.

SECTION VIII

HOME STUDY REQUEST FROM ANOTHER STATE

Outcomes of Home Study Process

There is not a required number of visits to a family to complete this process. The number ofvisits and contacts with the family and amount of information gathered will be determined basedon the following outcomes of the Home Study process:

1. Determination of and recommendation regarding the potential caregiver's ability to providea safe, secure environment for the child, and to work cooperatively with the worker andcourt;

2. Determination whether the placement will meet the best interest of the child as identified bythe requesting state;

3. Determination whether the placement will meet the identified needs of the child and therequesting state's expectations for the child, including the permanency objective of thechild;

4. Timely completion of the Home Study process - within 6 weeks of assignment to a workerwhenever possible;

5. Recommendation to the requesting state regarding placement and community resourceswhich will be needed to meet the needs of the family and child if placed;

6. Establishment of an orderly plan for child's placement in Nebraska.

Guidelines for Completion

The components listed below are guidelines for completing the Home Study process. Theydon't apply to all cases.

- Receive and review all information sent by the other state. Information should include:most recent court order, case plan and court report, other court reports and orders, socialstudy on the family and information on the child.

- Determine legal status of the child and the short-term and long-term plans of the requestingstate.

- Contact the worker from the requesting state for most recent and more detailedinformation, if needed.

- Visit the family and complete the Home Study using one of the formats in the FormsSection of this Guidebook. The home study includes: - Conduct law enforcement and CPS checks; - Contact and obtain references; - Gather any additional information which will assist with the assessment of the family; - Request that the family complete the Self-Study (optional). (See Forms Section in this

Guidebook); - Pursue negative reference, if received; - Discuss with the family their role and the expectations of the other state and court. Help

prepare the family for placement of child, if necessary; - Discuss how the family will locate and utilize community resources; - Document contact with the family and other relevant information; - Prepare the Home Study using one of the formats in the Forms Section of this Guidebook.

An approval study may be used for these cases.

When the Home Study process is completed, one copy of each of the following will be sent tothe Nebraska ICPC Administrator:

- Home Study, which includes a social history, results of the CPS and law enforcementchecks, the original copy of the Self-Study (if used);

- References, and any relevant follow-up documentation; and - Other relevant documents.

The Nebraska ICPC Administrator will make and send two copies of the Home Study andsupporting material to the ICPC Administrator in the requesting state.

Consultation Points

Staff completing the Home Study may consult with her or his supervisor, the case manager inthe requesting state, other Department staff or the ICPC Administrator at any point in theprocess.

Time Frame

The worker should complete the Home Study within six (6) weeks of receiving the request fromthe ICPC administrator. If the home study has been designated for priority processing, it needsto be completed and returned to the compact office with the recommendation for approval ordisapproval within sixteen (16) business days, if at all possible. The priority home study outlinemay be handwritten if legible. If the worker is unable to complete the study by the requesteddate, she/he will contact the Nebraska Compact Administrator with the reasons for the delayand arrive at a reasonable completion date .

SECTION IX

ACTION FOLLOWING PLACEMENT OF A CHILD INTO NEBRASKA

Worker Responsibilities

The worker assigned to the case will:

- Visit the child and family as needed, based on the Home Study and history of child;- Forward all written replies to the Nebraska ICPC Administrator for copying and forwarding

to sending state; - Work with the sending case manager and the family toward the case goal; - Coordinate with the Income Maintenance worker regarding obtaining medical coverage for

the child as appropriate; - Problem-solve with or assist the family in the following areas:

- Obtaining Medicaid for the child, - Payment complications; - Accessing needed services; - Obtaining financial assistance;

- Contact with parent or other family member as needed; - Assist with applying for or receiving approval for subsidized adoption or subsidized

guardianship; - Document in the case record all contacts, reports and other relevant information and

information requested by the sending state; and - Report on services provided and child and family progress to the sending state as

requested.

State wards from other states who are IV-E eligible can receive Nebraska Medicaid through theCOBRA process. They may also be eligible for Nebraska Medicaid due to Social Securityeligibility or the relatives' eligibility for financial assistance.

SECTION X

RESPONSES TO DIRECT REQUESTS FROM ANOTHER STATE

All requests to place a child in Nebraska in the placements covered by the Compact must gothrough the ICPC Administrator. If a worker or supervisor receives a written request directlyfrom another state, she/he will contact the Nebraska Administrator and forward to him/her allinformation received. Telephone requests for placement services should be referred to theNebraska ICPC Administrator.

SECTION XI

PLACEMENT OF A CHILD WHO IS NOT A WARD OUTSIDE OF NEBRASKA

Compliance with the Interstate Compact law is required for the placement of children who arenot wards into another state. If the worker or supervisor receives questions about this process,she/he may refer the person to the Nebraska Compact Administrator.

FORMS SECTION

Definition of VisitICPC-100A Request Instructions ICPC-100A Request FormICPC-100B Interstate Compact Report on Child's PlacementICPC Worker ChecklistICPC-101 Sending State Priority Home Study RequestICPC-101 InstructionsICPC-102 Receiving State's Priority Home Study ICPC-102 InstructionsSample Home Study Outlines

Reviewed/Revised 5/3/04

ICPC WORKER CHECKLIST

1. Identify possible out-of-state resource.

2. Contact resource to determine interest and begin discussion of financial and medicalpayment issues.

3. Determine financial and medical plan if child is placed out-of-state. Discuss situation withIM worker and Supervisor.

a. Is child IV-E eligible? b. Will placement be IV-E placement? Does home need to be licensed? c. What kind of maintenance payment will placement be eligible for?

FINANCIAL PLAN OPTIONS: 1) Nebraska HHSS will provide a foster care payment.

OR 2) This is a parent placement, therefore, Nebraska HHSS will expect the

parent to provide financially for the child.OR

3) The child will be placed with a relative and the relative will be asked toapply for TANF.

*IF the child is to be placed with a relative we cannot “force” the relative to take the TANFamount. NE cannot withhold foster care payment based upon the fact that the relative isnot licensed. However, NE HHSS can request that the relative become licensed,especially if the child is IV-E eligible so that NE HHSS can maximize IV-E reimbursement.The TANF amount is $222 per month for the first child and $70 per month for eachsubsequent child in Nebraska. Other states rates are similar. Be sure to determine if thatamount will be enough to provide basic support for the children. Older children or largesibling groups may need a larger foster care payment.

d. What will child's medical plan be?MEDICAL PLAN OPTIONS:

1. The child is IV-E eligible, therefore, Nebraska HHSS will send theappropriate COBRA documentation when the child is placed so theMedicaid may transfer to the other state.

OR 2. The child is not IV-E eligible. NE HHSS will provide a medical care or

reimbursement for the child’s medical expenditures incurred with priorapproval.

OR 3. The child would be returning to a parent. Therefore, it would be the

parents responsibility to provide for the child’s medical needs. 4. The child would be placed with a relative and NE HHSS would request that

the Relative apply for TANF and the medical coverage available with thatprogram.

*A relative can apply for TANF maintenance and TANF medical plans separately orjointly.

e. Who will provide care? You will need to identify those providers prior to placement. 1. Identify providers in the community in the other state, who are now

enrolled in NE Medicaid. 2. Contract with new providers willing to enroll in the NE Medicaid program.

Contact ICPC Office for contact person. 3. If not willing to enroll, are providers willing to accept payments from NE

child welfare funds at Medicaid rates?

4. For placements in an RTC:

a. Obtain Medicaid mental health managed care or Magellan approval. b. Complete and sign Placement Agreement and send to central office with other

required ICPC information.

5. Complete ICPC paperwork and send to central office. a. Individual 100A form for each child. Include social security number and IV-E

status. b. Current, signed court order, no older that 6 months, showing HHS custody. c. Recent case plan / court report, social history, medical or psychiatric reports,

school or other information about the child and situation. d. Cover letter explaining what is needed from the other state, any special

concerns. Include financial and medical plan. e. If requesting adoptive home study, you must show child is free for adoption.

Include relinquishments or termination orders.

6. Receive approval prior to placement of child.

7. After approval, but prior to placement, notify your IM FC worker to assure thatarrangements are made for medical services and maintenance payment.

8. Child may be placed. Be sure to send child's insurance information with him/her. Alsosend birth certificate, social security number and immunization records.

9. Complete and send in to ICPC in central office the 100B form with date of placementso that supervision will begin in the other state.

10. Complete financial arrangements. Verify and document that maintenance payment isestablished, doctor, dentist, pharmacist and therapists have been located andarrangements made for payment.

11. Monitor placement and services.

12. Request approval from ICPC office in receiving state PRIOR to recommending caseclosure. Case cannot legally be closed without approval of ICPC administrator in thereceiving state.

13. Complete 100B form to close case with approval of court and receiving state, if childreturns to NE, or if approved placement will not be used. Also, please attach copy ofclosing court order.

Revised 5/3/04

ASSOCIATION OF ADMINISTRATORS OF THE INTERSTATECOMPACT ON THE PLACEMENT OF CHILDREN

ICPC-101SENDING STATE PRIORITYHOME STUDY REQUEST

To be submitted by Social Worker with other required ICPC materials

Name of Child1 to be placed ______________________ Age _____ Mother's Name ______________________

Ethnic Group _____________________ DOB _____________ Father's Name__________________________PROPOSED CARETAKER

NAME: _________________________ Marital Status: S, M, Sep., D, W Living with ___________________(circle one) (name or person)

ADDRESS: _______________________________________________________________________________________

Telephone Home #: ___________________ Work #: ________________ Social Security #_________________

Relationship to child identified above: ___________________________________________________________

Best time of day to contact caretaker: __________ Employer ________________________________________(If applicable)

Alternate Contact Name & Address: ____________________________________________________________

_________________________________________________________________________________________

ASSESSMENT OF CHILD .Case Plan Attached: yes no Financial/ Medical Plan attached: yes no

(circle one) (circle one)

Special Needs: _______________________________________________________________________________

Handicaps: Mental/Physical ____________________________________________________________________

__________________________________________________________________________________________

Service Needs Treatment Requirements: _________________________________________________________

__________________________________________________________________________________________

School Information: _________________________________________________________________________

__________________________________________________________________________________________

Other required pertinent information regarding child and family will follow: yes no (circle one)

Worker's Name: _______________________________________________ __________________________(please print) (TeL #)

Worker's Signature: ______________________________________________________________________

(date)Supervisor's Signature _________________________________________ _________________________

(if required) (date) (TeL #)

1 If there is more than one child to be placed with the proposed caretaker, list the name of the child(ren) and allrequested information on a separate page and attach to this form.

CS-ICPC-101INSTRUCTIONS FOR COMPLETING FORM ICPC-101

SENDING STATE PRIORITY HOME STUDY REQUEST

PURPOSE: The purpose of form ICPC-101, Sending State Priority Home Study Request, isto alert the receiving state to the fact that the court which has jurisdiction over the child(ren) hasdetermined that a priority placement of a child from one state into another state isnecessary.

NUMBER OF COPIES AND ROUTING: Form ICPC-101 is to submitted with other required ICPCmaterials, to the ICPC Unit in Central Office.

Preparation of the form, together with compilation of other ICPC referral materials, is to becompleted within three (3) business days of receipt of a court order which indicates thecourt has determined that a Priority Placement situation exists.

A separate form is to be completed on each child who is included in the court's order forpriority placement.

Send the original and 2 copies to the ICPC Unit in Central Office. The fourth copy is to bereturned to the court which requested the priority placement for verification that the ICPCreferral was submitted on a timely basis. The fifth copy is to be retained by the worker in thechild's record.

Name of Child to be Placed: Enter the child's complete name, (last name, first name, andmiddle initial, if any).

Age: Enter the child's age as of the date the form, is completed.

Mother's Name: Enter the name of the mother of the child as found on the child's birthcertificate.

Ethnic Group: Enter the ethnic group to which the child belongs, i.e., Caucasian, African-American, Native American Indian, Hispanic, etc.

If the child belongs to more than one ethnic group, enter "Biracial" for the child's ethnicgroup membership.

DOB: Enter the child's date of birth as listed on the child's birth certificate.

Father's Name: Enter the name of the father of the child as found on the child's birthcertificate.

If there is no father listed on the birth certificate, list the name of the alleged father if known,and specify "alleged".

If the child's birth father is unknown, enter "unknown" on this line.

PROPOSED CARETAKER: This section relates to the person who will be providing care forthe child if placement occurs. The worker should make contact with the proposed caretakerto determine their interest in caring for the child if the court order does not indicate suchinformation.

Due to the time constraints for completing the home study, it is essential that all identifyinginformation about the proposed caretaker be included in the request for priority home study.

Name: Enter the name (last name, first name, middle initial) of the proposed caretaker.

Marital Status: Circle one of the entries to show the marital status of the proposedcaretaker, as follows:

S = Single

M = Married

Sep = Separated

D = Divorced

W = Widowed

Living with: Enter the name (last name, first name, middle initial) of the adult person withwhom the proposed caretaker is living, if any.

If the proposed caretaker is living alone (without any other adult in the home), leave thissection blank.

Address: Enter the complete address (street, apartment number, city, state, zip code) of theproposed caretaker.

If the address is a rural route, include the route number and box number of the proposedcaretaker.

Telephone Home #: Enter the home telephone number, including area code, of the proposedcaretaker.

If the proposed caretaker does not have a telephone, enter a message telephone number, ifpossible.

If the proposed caretaker does not have a home telephone number or a home messagetelephone number, enter "None" on this line.

Telephone Work #: Enter the work telephone number, including area code, of the proposedcaretaker.

If the employer does not allow the employee to receive telephone calls while on duty, specifythat information beside the telephone number.

If the proposed caretaker is not employed, leave this line blank.

Social Security #: Enter the social security number of the proposed caretaker, if known.Otherwise, leave this line blank.

Relationship to Child Identified Above: Self-explanatory. If applicable, specify paternal ormaternal to identify which side of the family is involved.

NOTE: Half relationships are considered the same as whole relationships (e.g., a "halfsister" is the same as a sister).

Step relationships are considered the same as if related by blood (e.g., a "stepbrother" is thesame as a brother).

A relationship "by marriage" terminates when death or divorce occurs, but if a child was bornof the married parents, the relationship between the parents continues even after themarriage is dissolved.

Termination of parental rights of a birth parent by a court severs all relationships betweenthe child, his/her parents, and all other relatives (either by blood or marriage).

Best time of day to contact caretaker: Enter "a.m." if the best time to contact the proposedcaretaker is between 8:00 a.m. and 12:00 Noon (local time of the caretaker).

Enter "p.m." if the best time to contact the proposed caretaker is between 12:00 Noon and5:00 p.m. (local time of the caretaker).

Enter "evening" and specify the time frame if the best time to contact the proposed caretakeris after 5:00 p.m. and before 9 p.m. (local time of the caretaker).

Employer: Enter the company name of the employer if the proposed caretaker is employed.

If the proposed caretaker is not to be contacted at their place of employment, indicate thisfact beside the name of the employer.

Alternate Contact Name & Address: Enter the name (last name, first name, middle initial)and address (street, apartment number, rural route and box numbers, city, state, and zipcode) of an alternate person who may be contacted in an effort to make contact with theproposed caretaker. Include the relationship of the contact person with the proposedcaretaker.

ASSESSMENT OF CHILD: This section relates to the child who will be placed with theproposed caretaker if placement is recommended by the receiving state CompactAdministrator and court approval for placement is given.

It is essential that sufficient information be provided to the, receiving state worker so that anadequate assessment can be completed which will take into account the needs of the childas well as the capacity of the proposed caretaker to provide appropriately for the child.

Case Plan Attached: Circle "yes" or "no" to indicate if the child's case plan is attached to thereferral. If a case plan has been completed, it must be attached to the referral.

Financial/Medical Plan attached: Circle "yes" or "no" to indicate if the financial and medicalplans for the child are attached to the referral.

If the proposed placement is with the child's parent, an entry may be made to indicate thatthe parent will be expected to assume financial and medical responsibility for the child byutilizing private resources or through applying for appropriate public aid.

In all other instances, financial and medical plans must be included with the referral toindicate how the child's financial and medical needs are to be met by the proposedcaretaker.

Special Needs: Enter a description of all special needs which require attention if the child isto be successfully placed with the proposed caretaker. If this information is containedelsewhere in the referral packet, enter the location for the information.

Special needs of the child include all medical, physical, emotional, behavioral, educational,and/or psychological areas of functioning.

Handicaps: Mental/Physical: Describe in detail all mental and/or physical handicaps whichthe child has and which must be taken into consideration in regard to the capability of theproposed caretaker to adequately care for those conditions. If this information is containedelsewhere in the referral packet, enter the location for the information.

Service Needs/Treatment Requirements: Enter all service needs and/or treatmentrequirements which must be addressed in order to achieve and maintain an acceptableplacement of the child with the proposed caretaker.

For each service need/treatment requirement listed, include the method by which paymentfor provision will be obtained, if such information is not included elsewhere in the referral,i.e., case plan, financial/medical plan, etc.

School Information: If the child is preschool age (less than age 5) on the date of theproposed placement, leave this section blank.

If the child is age 5 or older, enter the following information:

Name of school; grade last attended; report which includes most recent grades; if specialclassroom attendance is necessary due to child being learning disabled (LD) or behaviorallydisabled (BD); copies of child's Individualized Educational Plan (IEP), if applicable;recommendations of most recent teacher/counselor/principal regarding educational needs ofchild; if child is not attending school, give reason(s) for nonattendance.

Other Required Pertinent Information Regarding Child and Family Will Follow: Circle "yes" or"no" to indicate that additional case material will/will not be sent.

If "yes" is circled, indicate a tentative date for submitting the additional case material.

Worker's Name: Enter the name (first name, last name) of the worker who completed thisform. The information is to be printed.Telephone Number: Enter the worker's telephone number including area code. If applicable,include the extension number.iWorker's Signature: Self-explanatory.

Date Signed: Self-explanatory.

Supervisor's Signature: If required by local office policy, enter the signature of the immediatesupervisor of the worker.

Date Signed: Self-explanatory.

ASSOCIATION OF ADMINISTRATORS OF THE INTERSTATECOMPACT ON THE PLACEMENT OF CHILDREN

ICPC-102

RECEIVING STATE’S PRIORITYHOME STUDY

(Each section must be completed)

Name of Child1 to be placed ______________________ Age _____ Mother's Name ______________________

Ethnic Group ______________________________________ DOB __________________

Dates of telephone contact _________________________ Dates of Home Visits ___________________________________________ ___________________________________________ __________________

PROPOSED CARETAKER/SPOUSE

Name: ____________________________________________________ S.S. # _________________________

Address: ________________________________________________ Tel #s (Home) ______________________ (Work) ______________________

Marital Status: S, M, Sep., D, W Living with Name: _____________________________________(circle one)

Caretaker/Spouse: _____________________________________________________________________

Employer’s Name & Address: _____________________________________________________________

Telephone: _________________________________

YOU MUST SUBMIT INCOME VERIFICATION.Income: $ ___________ yearly ___________ monthly ___________ bi-weekly ________ weekly

(circle one)

Head of Household: ______________________________________ (Name on rent receipts, utility bills, etc.)Number of Members in Household: __________________________________________________________Relationship to proposed caretaker: __________________________________________________________

Length of relationship (if not marital): ___________________________________________________

Relationship of proposed caretaker to child: ______________________________________________

Reason for wanting to care for children: _______________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

How did you hear about child’s situation? ______________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

1 If there is more than one child to be placed with the proposed caretaker, list the name of the child(ren) and allrequested information on a separate page and attach to this form.

Do you understand the situation that caused this request? _________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

Ability to protect child from offender: __________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

Willingness to provide care (Time-limited?) (Open-ended?) ________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

Appropriateness of child care plans: __________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

Forms of discipline: _______________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

Is present income adequate? _______________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

Willingness (ability) to care for child without financial help: ________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

Willingness to accept/apply for AFDC? Yes ___ No ___

Requests Foster Care Benefits Yes ___ No ___

Willingness to undergo licensure? Yes ___ No ___

SPECIAL NEEDS

Ability of caretaker, community, schools to meet child/ren’s special needs: ___________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

OTHER ADULTS IN HOUSEHOLD (List separately/Use additional sheet to list household members if needed)

Name: ____________________________ Age: _____ Name: ___________________________ Age: ____Relationship to proposed caretaker:____________________________________________ __________________________________________Relationship to child to be placed:____________________________________________ __________________________________________Attitude towards placement:____________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ __________________________________________

OTHER CHILDREN IN HOUSEHOLD (List separately)

Name: ____________________________ Age: _____ Name: ___________________________ Age: ____Relationship to proposed caretaker:____________________________________________ __________________________________________Relationship to child to be placed:____________________________________________ __________________________________________Attitude towards placement:____________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ __________________________________________

School progress/problems:____________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ __________________________________________

Previous contacts with Public/Social Service Agencies: ___________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

CLEARANCES (In accordance with receiving state law)Law Enforcement/child abuse and neglect clearances for all household members who have reached the age ofmajority.

Police: _________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

Child Abuse and neglect: __________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

Family known to Public/Social Services Agencies (if yes, please explain): ____________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

HEALTHProposed caretaker and other family members tate that they are in basic, good health & free of communicablediseases: Yes ____ No ____

HOME and COMMUNITYAdequacy of space:

_______________________________________________________________________________________

_______________________________________________________________________________________

Will the child have his/her own bed? Yes ____ No ____ Closet space? Yes ____ No ____

Will the child share a bedroom? Yes ____ No ____ (if yes, list names(s) below)

With whom? _____________________________________________________________________________

Housekeeping Standards: __________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

Viewed potential hazards, safety problems (please specify): _______________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

Appropriateness of neighborhood: ___________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

Proximity to schools, medical services, etc.: ____________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

AREA OF CONCERNDid you visualize or anticipate any potential problem areas with the case (explain)? ____________________

_______________________________________________________________________________________

_______________________________________________________________________________________

CASE PLAN FROM SENDING STATEIs the submitted case plan suitable/adequate for this proposed placement? Yes ___ No ___ (if no explainbelow)

_______________________________________________________________________________________

_______________________________________________________________________________________

Do you have any recommended changes in the case plan or goal? _________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

Are there any restrictions, limitations you would place on the proposed family, the court, the placing agency?

_______________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

Financial/Medical Plan from Sending Sate: is it adequate for this child? Yes ___ No ___ (if no explain below)

_______________________________________________________________________________________

_______________________________________________________________________________________

STUDY NARRATIVEDiscuss any areas which cannot be addressed by this abbreviated study. Please expand or expound on anyarea which needs clarification. _______________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

Workers Recommendations: For Placement ____ Against Placement ____ (explain below)

_______________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

Comments (if appropriate): _________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

Please list conditions, if any for placement to occur: ______________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

Name of Worker: ____________________________ Name of Supervisor: ____________________________(please print) (please print)

Title: _______________________________________ Title: ______________________________________

Signature: _________________________________ Signature: ____________________________________

Date: _______________________________________ Date: ______________________________________

Tel. #: _____________________________________ Tel. #: ______________________________________

REFERENCESMade Contact Positive Negative

(please explain below)

Name: _____________________________________(yes) (no)

State Address: _______________________________ __________________________________________________________________________

City, State, Zip: ______________________________ __________________________________________________________________________

Telephone: (home) ___________________________ _____________________________________ (work) ___________________________ _____________________________________

Name: _____________________________________(yes) (no)

State Address: _______________________________ __________________________________________________________________________

City, State, Zip: ______________________________ __________________________________________________________________________

Telephone: (home) ___________________________ _____________________________________ (work) ___________________________ _____________________________________

Name: _____________________________________(yes) (no)

State Address: _______________________________ __________________________________________________________________________

City, State, Zip: ______________________________ __________________________________________________________________________

Telephone: (home) ___________________________ _____________________________________ (work) ___________________________ _____________________________________

Revised 4/21/041

CS-ICPC-102INSTRUCTIONS FOR COMPLETING FORM ICPC-102

RECEIVING STATE'S PRIORITY HOME STUDY

PURPOSE: The purpose of form ICPC-102, Receiving State's Priority Home Study, is toprovide a form on which a relative home study can be completed whenever a child is proposedto be placed with the child's parent, step-parent, grandparent, adult brother or sister, or adultuncle or aunt in Nebraska and the proposed placement has been classified as a "priorityplacement" by the court having jurisdiction over the child or whether the court has created apriority placement order under Regulation No. 7 Section 5 (b).

NUMBER OF COPIES AND ROUTING: Form ICPC-102 is 8 pages in length; uponcompletion, it is to be submitted by the caseworker to the ICPC Unit.

The form may be completed in longhand to conserve time in completing the home study.

Each section of the form must be completed by either entering the required information or byentering "Not Applicable" to any section which does not apply to the specific case situation.

Send the original and 2 copies to the ICPC Unit in Central office. The worker is to keep one copy inthe relative's record.

Name of Child To Be Placed: Enter the child's name (last name, first name, and middleinitial, if any).

If more than one (1) child is proposed to be placed with the caretaker, list all additionalchildren on a separate sheet of paper and attach the sheet to the back of the home study.

Age: Enter the age of the child who is proposed to be placed as of the date form ICPC-102 iscompleted.

If more than one (1) child is proposed to be placed with the caretaker, list each additional child'sage on the shoot identified above beside each child's name.

Sending State: Enter the name of the state who issued form ICPC-1 01; e.g., Illinois, Kansas, etc.Ethnic Group: Enter the ethnic group to which the child belongs as shown on form ICPC-101.

If more than one (1) child is proposed to be placed with the caretaker, list each additional child'sethnic classification on the sheet identified above beside the child's name and age.

DOB: Enter the child's date of birth as listed on form ICPC-101.

If more than one (1) child is proposed to be placed with the caretaker, list each additionalchild's date of birth on the sheet identified above beside the child's name, age and date ofbirth.

Dates of Telephone Contact: Enter the date(s) (mm/dd/yy) on which telephone contact was madeby the worker with the proposed caretaker.

Dates of Home Visits: Enter the dates (mm/dd/yy) on which each home visit was made by theworker with the proposed caretaker.

NOTE: At a minimum, one (1) home visit with the proposed caretaker must be made.

Revised 4/21/042

PROPOSED CARETAKER/SPOUSE: This section relates to the proposed caretaker and spouse,if applicable. It is essential that complete information be entered to answer each question.

Name: Enter the name (last name, first name, middle initial) of the proposed caretaker.This information must agree with the same information contained on form ICPC-1 01.

If the name does not agree with information on form ICPC-101, contact the ICPC Unit inCentral office for instruction before completing the remainder of this form.

Social Security #: Enter the social security number of the proposed caretaker.

If the caretaker does not have a social security number, enter "none" on this line.

Address: Enter the address (street, apartment number, city, state, and zip code) of theproposed caretaker.

If the address is a rural route, include the route number and box number of theproposed caretaker.

Telephone #s (Home): Self-explanatory. Include area code.(Work): Self-explanatory. Include area code.

If the proposed caretaker does not have a telephone, enter a message telephonenumber, if possible.

If the proposed caretaker does not have a telephone number or a message telephonenumber, enter "None" on this line/these lines.

Employer's Name and Address: Enter the company name and address of the employer, ifthe proposed caretaker is employed.

Marital Status: Circle one of the entries to show the marital status of the proposed caretaker,as follows:

M = Married

S = Single

Sep = Separated

D = Divorced

W = Widowed

Living With: Name Enter the name (last name, first name, middle initial) of the adultperson (other than legal spouse) with whom the proposed caretaker is living, if any.

If the proposed caretaker is living alone (without any other adult in the home), enter"Not Applicable" in this section.

Caretaker/Spouse: Enter the name (last name, first name, middle initial) of thecaretaker's spouse, if these individuals are legally married.

Spouse's Employers Name and Address: Enter the company name and address of theemployer of the caretaker's spouse, if employed.

Revised 4/21/043

Otherwise, enter "Not Applicable" in this section.

Telephone: Enter the work telephone number, including area code, of the employer of thecaretaker's spouse.

If the employer does not allow the employee to receive telephone calls while on duty, specify thatinformation beside the telephone number.

If the caretaker's spouse is not employed, enter "Not Applicable" on this line.

YOU MUST SUBMIT INCOME VERIFICATION

Income: Enter a dollar amount for the gross income of the household and circle the entry whichreflects the pay period involved.

Head of Household: Enter the name of the adult (age 18 or older) who is considered to be thehead of the household as evidenced by the name on rent receipts, utility bills, etc.

Number of Members in Household: Enter the number of adults age 18 or over and thenumber of children under the age of 18 in the household; use the designation A for Adults and Cfor children, e.g., A = 2 and C = 1 to indicate there are 2 persons age 18 or over and 1 childunder the age of 18 in the home.

Relationship to proposed caretaker: Enter the relationship of the proposed caretaker to the headof household, if applicable.

If the head of household and proposed caretaker is the same person, enter "same" on this line.

Length of Relationship (if not marital): Enter the length of time the proposed caretaker andhead of household have had a relationship.

If the head of household and proposed caretaker is the same person, enter "same" on this line.

Relationship of proposed caretaker to child: Enter the relationship between the proposedcaretaker and the child who is being considered for placement in this home. If applicable,specify paternal or maternal to identify which side of the family is involved.

NOTE: Half relationships are considered the same as whole relationships (e.g., a "half sister" isthe same as a sister).

Step relationships are considered the same as if related by blood (e.g., a "stepbrother" is thesame as a brother).

A relationship "by marriage" terminates when death or divorce occurs, but if a child was born ofthe married parents, the relationship between the parents continues even after the marriageis dissolved.

Legal relationships between the child and members of the extended family may be alteredwhenever a court has terminated parental rights of the birth parents.

If the parental rights of only one birth parent have been terminated by the court, the child'srelationship to the other birth parent (and the relatives of that birth parent) remains in effect.

Reason for wanting to care for children: Enter the reason given by the proposed caretaker forwanting to care for this child/these children and include your assessment of the response.

Revised 4/21/044

How did you hear about child's situation? Enter the response of the proposed caretaker tothis question and include your assessment of the response.

Do you understand the situation that caused this request? Enter the response of theproposed caretaker to this question and include your assessment of the response.

Ability to protect child from offender: Enter your assessment of the ability of the proposedcaretaker to protect the child from the person who perpetrated abuse or neglect.

Willingness to provide care (time limited or open ended?): Enter the response of theproposed caretaker to this question and include your assessment of the response.

Appropriateness of child care plans: Enter the response of the proposed caretaker tothis question and include your assessment of the response. Include any necessaryexplanation if the proposed caretaker does not plan to utilize child care or if the child tobe placed with the caretaker does not require child care.

Forms of Discipline: Enter the form(s) of discipline which the proposed caretaker plans touse. This section must include information about corporal punishment (will/will not be used).

Is Present Income Adequate? Enter your assessment of the adequacy of the income in the home tomeet both (a) current expenses and (b) the additional expenses if the child is placed in thehome.

Willingness (ability) to care for child without financial help: Check "yes" or "no" asappropriate for the response of the caretaker.

Willingness to accept/apply for AFDC? Check "yes" or "no' as appropriate for the responseo the caretaker.

Requests Foster Care benefits? Check "yes" or "no" as appropriate for the response ofthe caretaker.

Willingness to undergo licensure? Check "yes" or "no" as appropriate for the response ofthe caretaker.

SPECIAL NEEDS

Ability of caretaker, community, schools to meet child/ren's special needs: Using theinformation contained on form ICPC-1 01, enter your assessment of the caretaker's ability tomeet the child's special needs as well as the resources available in the schools and community tomeet the child's special needs.

If the child does not have any special needs, enter "not applicable" in this section.

OTHER ADULTS IN HOUSEHOLD (List separately/use additional sheet to listhousehold members if needed).

Name, Age, Relationship to proposed caretaker, Relationship to child to be placed,Attitude towards placement: Enter the appropriate information for each adult age 18 orover in the household.

OTHER CHILDREN IN HOUSEHOLD (list separately)

Revised 4/21/045

Name, age, Relationship to proposed caretaker, Relationship to child to be placed, Attitudetowards placement: Enter the appropriate information for each child in the household.

If child(ren) in household are too young to respond to "attitude towards placement" enter "childtoo young" in this section beside that child's name.

School Progress/Problems: For each child in the household who is school age, enter theprogress problems being encountered in school.

If no child in the household is school age, enter "not applicable" in this section.

Previous contacts with Public/Social Service Agencies: Enter the response of the caretaker tothis question; include all previous contacts of each member of the household with eachpublic/social service agencies, describing the date(s) of contact; type(s) of contact; servicesoffered/provided; outcome(s), etc.

CLEARANCES: (in accordance with receiving state law)

Law Enforcement/child abuse and neglect clearances for all household members who havereached age of majority: For each adult member of the household, enter the appropriateinformation as requested. If, for some reason, law enforcement and/or child abuse/neglectclearances were not completed, please explain.

Police: Enter applicable information or explanation if no clearance was made.

Child Abuse and Neglect: Enter applicable information or explanation if no clearance wasmade. Family known to Public/Social Services Agencies (if yes, please explain): Self-explanatory.

If the family has not been known to any public and/or social services agencies, enter "notapplicable" in this section.

HEALTH:

Proposed caretaker and other family members state that they are in basic, good health andfree of communicable diseases: Check "yes" or "no" as applicable. If no, attach separate pageof explanation.

HOME AND COMMUNITY

Adequacy of space: Enter your assessment of the home of the proposed caretaker in relation toits adequacy to accommodate the child who is being considered for placement.

Will the child have his/her own bed? Circle "yes" or "no" to answer this question. If no,explain.

will the child have his/her own closet space? Circle "yes" or "no" to answer this question. Ifno, explain.

Will the child share a bedroom? Circle "Yes" or "no" to answer this question. (If "yes" iscircled, list name(s) below).

With whom? If the previous question was answered "yes," enter the name(s) of each child withwhom the child will be sharing a bedroom.

Revised 4/21/046

Housekeeping standards: Enter your assessment of the housekeeping standards of theproposed caretaker, taking into account the needs of the child who is being considered forplacement.

Viewed potential hazards, safety problems (please specify) Enter your assessment ofany potential hazards or safety problems which could/would impact on the child who isbeing considered for placement.

If no potential hazards or safety problems are observed, enter "none" in this section.

Appropriateness of neighborhood: Enter your assessment of the caretaker's neighborhood, takinginto account the needs of the child who is being considered for placement.

Proximity to schools, medical services, etc.: Enter your assessment of the proximity of communityresources being available to the caretaker and the child being considered for placement,taking into account the special needs, if any, of the child.

AREA OF CONCERN:

Did you visualize or anticipate any potential problem areas with this case (explain)?Self-explanatory.

CASE PLAN FROM SENDING STATE:

Is the submitted case plan suitable/adequate for this proposed placement? Circle "yes" or"no" and, if no, explain in the space provided.

Do you have any recommended changes in the case plan or goal? Self-explanatory. Ifnone, enter "none" in this section.

Are there any restrictions, limitations you would place on the proposed family, the court,the placing agency? This question is self-explanatory. Enter as much detail as necessary toexplain your responses.

If none, enter "none" in this section.

Financial/Medical Plan from Sending State: Is it adequate for this child? Circle "yes" or "no"and if no, explain in the space provided.

STUDY NARRATIVE

Discuss any areas which cannot be addressed by this abbreviated study.. Pleaseexpand or expound on any area which needs clarification. Self-explanatory.

Worker's Recommendation: Check "For Placement" or "Against Placement" as applicable. Ifthe recommendation is against placement, please explain.

NOTE: THE FORM WILL NOT BE ACCEPTED BY THE ICPC UNIT OR THE SENDINGAGENCY IF THIS SECTION IS LEFT BLANK.

Comments: (If appropriate) Self-explanatory.

Name of Worker: Please print the name of the worker who completed this home study.

Name of Supervisor: Please print the name of the workers immediate supervisor.

Revised 4/21/047

Title: Enter the worker's job title on the left side of the page and the supervisor's tile on theright side of the page.

Signature: The worker who completed this home study is to sign his/her name in this sectionon the left side and, if appropriate, the immediate supervisor of the worker is to sign his/her namein this section on the right side.

Date: Enter the date on the left side of the page when the worker signed the form.

Enter the date on the right side of the page when the worker's supervisor signed the form, ifapplicable.

Telephone Number of Worker and Supervisor: The worker and the supervisor of the workerare to enter their respective work telephone number, including area code and, if applicable, theirextension.

REFERENCES: Space is provided to enter information for three (3) references as given bythe proposed caretaker.

Enter the name, street address, city, state, zip code, home telephone number and, ifapplicable, the work telephone number for each reference given by the proposed caretaker.

Beside each identified reference, check the box "yes" or "no" to indicate whether or notcontact was made with the reference.

Beside each identified reference who was contacted, check the box "positive" or "negative" toindicate the information given by the reference was positive or negative in regard to the proposedcaretaker and the plan to place the child with the proposed caretaker.

If a reference gives a negative report, please explain the information on the lines provided.

ICPC GUIDEBOOK

Reviewed 5/3/04